For years, artificial sweeteners like erythritol were hailed as a solution to reduce sugar intake without sacrificing sweetness. Marketed towards individuals with diabetes, people on keto diets, and those looking to manage their weight, these zero-calorie alternatives have become ubiquitous in processed foods. However, recent and concerning research has complicated this narrative, forcing a closer look at whether these sugar substitutes are as harmless as once believed.
What Is Erythritol?
Erythritol is a type of sugar alcohol, or polyol, that is found naturally in small amounts in certain fruits and fermented foods. However, the erythritol used in most modern processed foods is commercially manufactured, typically through the fermentation of cornstarch. It is about 70% as sweet as table sugar, but contains virtually no calories because it is poorly metabolized by the body. The vast majority of ingested erythritol is absorbed in the small intestine and excreted unchanged in the urine.
The Case Against Sugar
It is widely understood that excessive consumption of table sugar (sucrose) poses significant health risks. A diet high in added sugars is associated with several adverse health outcomes:
- Blood Sugar Spikes: Sugar causes rapid increases in blood glucose and insulin levels, which can contribute to metabolic issues and type 2 diabetes over time.
- Weight Gain and Obesity: The caloric density of sugar and its impact on hormonal regulation contribute to weight gain.
- Cardiovascular Disease: High sugar intake has been linked to increased risk factors for heart disease, including high blood pressure and elevated triglycerides.
- Dental Decay: Oral bacteria feed on sugar, producing acids that erode tooth enamel and cause cavities.
The Surprising New Evidence on Erythritol and Heart Health
In a major shift, a 2023 study from the Cleveland Clinic, published in Nature Medicine, unexpectedly found a strong correlation between high circulating levels of erythritol and an increased risk of heart attack and stroke. Researchers, who were not originally looking for a connection to erythritol, observed this link in a population of high-risk individuals with pre-existing heart disease.
Further mechanistic studies conducted in the lab demonstrated that erythritol enhanced platelet activity, leading to heightened blood clot formation. A subsequent human intervention study showed that after consuming a single drink with 30 grams of erythritol, blood levels of the compound rose a thousandfold and remained elevated for days, surpassing the threshold linked to enhanced clotting risk. It is important to note that the subjects in the initial observational studies were already at increased cardiovascular risk, but the findings warrant significant caution.
Comparing Erythritol and Sugar
| Feature | Erythritol | Table Sugar (Sucrose) |
|---|---|---|
| Calories | Virtually zero | Approximately 4 calories per gram |
| Glycemic Index (GI) | 0 | 65 |
| Blood Sugar Impact | Does not spike blood sugar or insulin | Causes rapid spikes in blood sugar and insulin |
| Dental Health | Does not promote tooth decay; may inhibit oral bacteria | Major contributor to cavities and dental decay |
| Cardiovascular Risk | Linked to increased blood clotting and higher risk of heart attack/stroke, especially at high intake in at-risk individuals | Contributes to established cardiovascular disease risk factors like obesity and diabetes |
| Digestive Impact | Well-tolerated at moderate doses, but high amounts can cause gas, bloating, and diarrhea | Generally digested well, but excessive intake can contribute to broader metabolic issues |
| FDA Status | 'Generally Recognized as Safe' (GRAS), but some call for re-evaluation | Standard food ingredient, but dietary guidelines recommend limiting intake |
Navigating Your Sweetener Choices
Given the recent findings, what is the best approach to sweeteners? For many, the ultimate goal is to reduce reliance on all forms of added sweeteners, both sugar and its substitutes. For high-risk individuals with pre-existing cardiovascular conditions or diabetes, consulting a healthcare provider and limiting high-dose erythritol products may be prudent. Focusing on whole foods as a source of sweetness, like fruits, is a recommended strategy.
- Prioritize Whole Foods: Use fresh or frozen fruits, like berries and bananas, to sweeten dishes and drinks naturally, as they also provide fiber and essential nutrients.
- Read Labels Carefully: Check ingredient lists for erythritol, especially in keto, 'sugar-free,' or 'naturally sweetened' products, as it is often a bulking agent for other sweeteners like stevia and monk fruit.
- Consider Stevia and Monk Fruit (in Pure Forms): These potent non-caloric sweeteners have been shown to be safer than some other alternatives, provided they aren't bulked up with erythritol.
- Use Sugar Moderately and Occasionally: For some, small, infrequent amounts of real sugar or natural options like honey or maple syrup may be a safer choice than high doses of erythritol, given the current cardiovascular risk concerns.
Conclusion: Is Erythritol Worse Than Sugar?
The question of whether erythritol is worse than sugar has no simple answer. For decades, erythritol seemed like a clear winner, especially for blood sugar control and dental health. However, new research suggests that in high doses, especially for at-risk populations, it carries unique cardiovascular risks linked to blood clot formation. While sugar's negative health effects are well-documented, they manifest differently over time, without the immediate-onset clotting risk seen with high erythritol doses. The most prudent takeaway is to treat all processed sweeteners—sugar and alternatives alike—with caution and focus on reducing your intake overall. For those concerned about heart health, limiting processed foods containing large amounts of erythritol is a sensible precaution until further long-term studies are conducted.
